Comparison of Anesthesia-Controlled Operating Room Time between Propofol-Based Total Intravenous Anesthesia and Desflurane Anesthesia in Open Colorectal Surgery: A Retrospective Study

Narrative Review of Prolonged Times to Tracheal Extubation After General Anesthesia With Intubation and Extubation in the Operating Room

This narrative review summarizes research about prolonged times to tracheal extubation after general anesthesia with both intubation and extubation occurring in the operating room or other anesthetizing location where the anesthetic was performed. The literature search was current through May 2023 and included prolonged extubations defined either as >15 minutes or at least 15 minutes. The studies showed that prolonged times to extubation can be measured accurately, are associated with reintubations and respiratory treatments, are rated poorly by anesthesiologists, are treated with flumazenil and naloxone, are associated with impaired operating room workflow, are associated with longer operating room times, are associated with tardiness of starts of to-follow cases and surgeons, and are associated with longer duration workdays. When observing prolonged extubations among all patients receiving general anesthesia, covariates accounting for most prolonged extubations are characteristics of the surgery, positioning, and anesthesia provider's familiarity with the surgeon. Anesthetic drugs and delivery systems routinely achieve substantial differences in the incidences of prolonged extubations. Occasional claims made that anesthesia drugs have unimportant differences in recovery times, based on medians and means of extubation times, are misleading, because benefits of different anesthetics are achieved principally by reducing the variability in extubation times, specifically by decreasing the incidence of extubation times sufficiently long to have economic impact (ie, the prolonged extubations). Collectively, the results show that when investigators in anesthesia pharmacology quantify the rate of patient recovery from general anesthesia, the incidence of prolonged times to tracheal extubation should be included as a study end point.

The Total Intra Venous Anesthesia Effect Versus Volatile Anesthesia, on Stress and Pain Levels, in Patients Undergoing Breast Reconstruction in Ambulatory Surgery Center Total Intra Venous Anesthesia Protocol and Stress Response

AIM

To compare pain and stress response through cortisol and DHEA levels, implementing. Total intra venous anesthesia (TIVA) versus general anesthesia with volatile anesthetics (VOL).

DESIGN

This is a prospective randomized correlation study with consecutive measurements.

METHODS

In an ambulatory surgical center from October of 2019 to August of 2020, patients who underwent breast reconstruction with autologous fat grafting were randomized into 2 groups. Patients in the TIVA group (n = 23) received intravenous anesthesia and those in the VOL group (n = 23) received volatile anesthesia (desflurane). Demographic, anthropometric and clinical data were recorded. Arterial systolic (SP) and diastolic (DP) blood pressure, heart rate and oxygen saturation were recorded. Pain and stress levels were evaluated through salivary cortisol and DHEA levels at 4 different time points: T0) 1 hour before induction, T1) during the induction, T2) during anesthesia maintenance, and T3) in recovery phase. Statistical analysis was performed with SPSS 25.0 at significant level α = .05.

FINDINGS

There were no statistically significant differences between the 2 groups regarding demographic features. Interestingly that there was a statistically significant difference in the vital sign monitoring where patients in the TIVA group reported with higher levels of SP(T2) and DP (T2), whilst DHEA (T1) levels was correlated positively with patient's age and cortisol (T1) levels and negatively with DP (T3).

CONCLUSIONS

This study supports the use of TIVA as a safe and effective option for anesthesia in patients undergoing breast reconstruction with autologous fat grafting.

Benchmarking of Anesthesia and Surgical Control Times by Current Procedural Terminology (CPT®) Codes

Over half of hospital revenue results from perioperative patient care, thus emphasizing the importance of efficient resource utilization within a hospital's suite of operating rooms (ORs). Predicting surgical case duration, including Anesthesia-controlled time (ACT) and Surgical-controlled time (SCT) has been significantly detailed throughout the literature as a means to help manage and predict OR scheduling. However, this information has previously been divided by surgical specialty, and only limited benchmarking data regarding ACT and SCT exists. We hypothesized that advancing the granularity of the ACT and SCT from surgical specialty to specific Current Procedural Terminology (CPT^®) codes will produce data that is more accurate, less variable, and therefore more useful for OR schedule modeling and management. This single center study was conducted using times from surgeries performed at the University of Colorado Hospital (UCH) between September 2018 - September 2019. Individual cases were categorized by surgical specialty based on the specialty of the primary attending surgeon and CPT codes were compiled from billing data. Times were calculated as defined by the American Association of Clinical Directors. I² values were calculated to assess heterogeneity of mean ACT and SCT times while Levene's test was utilized to assess heterogeneity of ACT and SCT variances. Statistical analyses for both ACT and SCT were calculated using JMP Statistical Discovery Software from SAS (Cary, NC) and R v3.6.3 (Vienna, Austria). All surgical cases (n = 87,537) performed at UCH from September 2018 to September 2019 were evaluated and 30,091 cases were included in the final analysis. All surgical subspecialties, with the exception of Podiatry, showed significant variability in ACT and SCT values between CPT codes within each surgical specialty. Furthermore, the variances of ACT and SCT values were also highly variable between CPT codes within each surgical specialty. Finally, benchmarking values of mean ACT and SCT with corresponding standard deviations are provided. Because each mean ACT and SCT value varies significantly between different CPT codes within a surgical specialty, using this granularity of data will likely enable improved accuracy in surgical schedule modeling compared to using mean ACT and SCT values for each surgical specialty as a whole. Furthermore, because there was significant variability of ACT and SCT variances between CPT codes, incorporating variance into surgical schedule modeling may also improve accuracy. Future investigations should include real-time simulations, logistical modeling, and labor utilization analyses as well as validation of benchmarking times in private practice settings.

Changes in the Plasma Apurinic/Apyrimidinic Endonuclease 1/Redox Factor-1(APE1/Ref-1) Level during Cancer Surgery: An Observational Study

Background and Objectives: Propofol-based total intravenous anesthesia (TIVA) is presumed to have more favorable effects on the prognosis of patients with cancer compared with volatile inhaled anesthesia (VIA). We hypothesized that these anesthetics target plasma apurinic apyrimidinic endonuclease/redox effector factor-1 (APE1/Ref-1) as a possible mechanism of action. Materials and Methods: The plasma APE1/Ref-1 level was evaluated three times during surgery for cancer, i.e., before anesthesia, immediately after cancer resection, and finally, in the recovery room. Blood (3 cc) was drawn from the radial artery catheter, and plasma APE1/Ref-1 levels were compared according to measurement time and between the two groups. Spearman’s Rho correlation analysis was performed to determine relationships among body mass index, American Society of Anesthesiologists classification, age, sex, cancer type, and tumor-node-metastasis (TNM) stage. A total of 166 patients (VIA: 129; TIVA: 37) were enrolled. Results: Plasma APE1/Ref-1 level increased significantly (p = 0.028) after cancer resection compared with before surgery, but no significant difference was observed between anesthetics (p = 0.134). The post-resection plasma APE1/Ref-1 level showed a positive correlation with the NM stages, but not the T stage. Conclusions: The plasma APE1/Ref-1 level increased during surgery with more severe lymph node invasion, but there were no significant differences according to the anesthetics used.

Propofol-based total intravenous anesthesia decreases the incidence of postoperative nausea and vomiting without affecting flap survival in free flap breast reconstruction

Background

Postoperative nausea and vomiting (PONV) may cause undesirable effects after microsurgical breast reconstruction. Although total intravenous anesthesia (TIVA) with propofol has been demonstrated to be effective in reducing PONV, it has not been assessed in autologous free flap breast reconstruction. The purpose of this study was to investigate the antiemetic prophylaxis effect and safety of TIVA in microvascular breast reconstruction.

Methods

Eighty-three patients undergoing microsurgical breast reconstruction with propofol (31 patients) or sevoflurane (52 patients) were retrospectively reviewed. The incidence of PONV was assessed at 2, 6, and 24 hours after surgery. Mean arterial blood pressure (MAP) was compared at T₁ (after flap elevation but before transfer), T₂ (15 minutes after revascularization), and T₃ (at the end of surgery).

Results

The incidence of nausea was significantly reduced in the TIVA group over 0 to 2 hours period (P=0.017), and over 2 to 6 hours period (P=0.033). The incidence of vomiting was significantly reduced in the TIVA group over 0 to 2 hours period (P=0.006), and over 2 to 6 hours period (P=0.005). MAP was higher in the TIVA group at T₁ (P=0.018), T₂ (P=0.005), and T₃ (P=0.007). The incidence of flap failure was similar between the two groups (P=0.373).

Conclusions

Compared with sevoflurane maintaining anesthesia, propofol-based TIVA improves PONV with less fluctuation of MAP, and did not affect flap survival.

Effect of Patient State Index Monitoring on the Recovery Characteristics in Morbidly Obese Patients: Comparison of Inhalation Anesthesia and Total Intravenous Anesthesia

PURPOSE

Obese patients have a significantly higher risk of adverse effects associated with general anesthesia. The purpose of this study was to evaluate the effects of Patient State Index (PSI) monitoring on recovery from anesthesia and the incidence of any postoperative complications among patients undergoing bariatric surgery with total intravenous anesthesia (TIVA) and inhalational anesthesia.

DESIGN

This prospective, double-blind, and randomized controlled trial was conducted between February 2017 and August 2017 and included 120 morbidly obese patients (body mass index >40 kg/m²).

METHODS

Patients were randomly divided into four groups; group P-PSI (n = 30): TIVA with PSI monitoring; group P (n = 30): TIVA without PSI monitoring; group D-PSI (n = 30): desflurane with PSI monitoring; and group D (n = 30): desflurane without PSI monitoring. The discharge time from the postanesthesia care unit (PACU), postoperative complications, and hemodynamic parameters were recorded and evaluated.

FINDINGS

No significant differences were found in demographic data, duration of anesthesia, admittance to PACU, discharge from PACU, modified Aldrete scores, and perioperative mean blood pressure and heart rate. Nausea and vomiting scores were significantly lower in group P-PSI, group P, and group D-PSI compared with group D.

CONCLUSIONS

Although TIVA and inhalational anesthesia can be safely used for obese patients, intraoperative PSI monitoring may decrease the discharge time from PACU and reduces incidence of postoperative nausea and vomiting caused by inhalation anesthetics.

Can high-volume teams of anesthesiologists and surgeons decrease perioperative costs for pancreatic surgery?

BACKGROUND

Pancreatic surgery outcomes are associated with surgeon and center experience. Anesthesiologists as potential value drivers for pancreatic surgery have not been explored. We sought to evaluate whether anesthesiologists impact perioperative costs for pancreatic surgery.

METHODS

Within an integrated health care system, 796 pancreatic surgeries (526 PDs and 270 DPs) were performed from January 2014 to June 2017. Mean direct operative and anesthesia costs driven by anesthesiologists (operating room (OR) time, anesthesia billing and anesthesia procedures) were determined for each case. The volumes of pancreatic cases per anesthesiologist were calculated, and those above the 75th percentile for volume (4 cases) were considered high-volume. A multivariable analysis of OR/anesthesia costs was performed.

RESULTS

Mean OR and anesthesia costs for PD were $7064 for low-volume anesthesiologists (LVA), higher than $5968 for high-volume anesthesiologists (HVA) (p < 0.001). By multivariable analysis, HVA were associated with decreased costs of $2278 (p < 0.001). Teams of HVA and high-volume surgeons (HVS) were also associated with decreased mean costs of $1790 (p = 0.04).

CONCLUSION

These data suggest that anesthesiologists experienced in the management of complex pancreatic operations such as PDs may contribute to improved efficiencies in care by reducing perioperative costs.

Developing a personalized closed-loop controller of medically-induced coma in a rodent model

OBJECTIVE

Personalized automatic control of medically-induced coma, a critical multi-day therapy in the intensive care unit, could greatly benefit clinical care and further provide a novel scientific tool for investigating how the brain response to anesthetic infusion rate changes during therapy. Personalized control would require real-time tracking of inter- and intra-subject variabilities in the brain response to anesthetic infusion rate while simultaneously delivering the therapy, which has not been achieved. Current control systems for medically-induced coma require a separate offline model fitting experiment to deal with inter-subject variabilities, which would lead to therapy interruption. Removing the need for these offline interruptions could help facilitate clinical feasbility. In addition, current systems do not track intra-subject variabilities. Tracking intra-subject variabilities is essential for studying whether or how the brain response to anesthetic infusion rate changes during therapy. Further, such tracking could enhance control precison and thus help facilitate clinical feasibility.

APPROACH

Here we develop a personalized closed-loop anesthetic delivery (CLAD) system in a rodent model that tracks both inter- and intra-subject variabilities in real time while simultaneously controlling the anesthetic in closed loop. We tested the CLAD in rats by administrating propofol to control the electroencephalogram (EEG) burst suppression. We first examined whether the CLAD can remove the need for offline model fitting interruption. We then used the CLAD as a tool to study whether and how the brain response to anesthetic infusion rate changes as a function of changes in the depth of medically-induced coma. Finally, we studied whether the CLAD can enhance control compared with prior systems by tracking intra-subject variabilities.

MAIN RESULTS

The CLAD precisely controlled the EEG burst suppression in each rat without performing offline model fitting experiments. Further, using the CLAD, we discovered that the brain response to anesthetic infusion rate varied during control, and that these variations correlated with the depth of medically-induced coma in a consistent manner across individual rats. Finally, tracking these variations reduced control bias and error by more than 70% compared with prior systems.

SIGNIFICANCE

This personalized CLAD provides a new tool to study the dynamics of brain response to anesthetic infusion rate and has significant implications for enabling clinically-feasible automatic control of medically-induced coma.

Early postoperative recovery in operating room after desflurane anesthesia combined with Bispectral index (BIS) monitoring and warming in lengthy abdominal surgery: a randomized controlled study

BACKGROUND

This study aimed to determine whether the use of desflurane (DES) anesthesia combined with bispectral index (BIS) monitoring and warming is effective in reducing anesthesia-controlled operating room time (ACT) in patients undergoing lengthy abdominal surgery.

METHODS

Seventy patients, 40 years of age or older, undergoing abdominal surgery expected to last three to five hours were randomly assigned to the DES group (n = 35) or the control group (n = 35). Patients in the DES group were maintained with desflurane anesthesia and received BIS monitoring and warming. Patients in the control group were given non-desflurane anesthesia for maintenance, and the usage of BIS monitoring and warming were not mandatory and determined by anesthesia care providers. Early postoperative recovery times were recorded.

RESULTS

The times to extubation (8.8 ± 8.5 vs 14.7 ± 13.7 min, P = 0.035), eye opening (8.4 ± 8.6 vs 14.4 ± 13.4 min, P = 0.028), responds on command (8.2 ± 8.5 vs 14.4 ± 13.0 min, P = 0.022), and the ACT (23.8 ± 11.4 vs 32.7 ± 15.4 min, P = 0.009) were significantly less in the DES group than that in the control group. The postanesthesia care unit (PACU) length of stay, incidence of prolonged extubation, and surgeon and anesthesiologist satisfaction were similar in two groups. Also, the result of multivariable linear regressions showed that patients who were younger, female, lower BMI and non-DES anesthesia regimen resulted in prolonged extubation.

CONCLUSIONS

Desflurane anesthesia combined with BIS monitoring and warming is associated with early postoperative recovery in lengthy abdominal surgery.

TRIAL REGISTRATION

ChiCTR-INR-17013333 . Date of registration: November 11, 2017.

Frontal EEG Temporal and Spectral Dynamics Similarity Analysis between Propofol and Desflurane Induced Anesthesia Using Hilbert-Huang Transform

Electroencephalogram (EEG) signal analysis is commonly employed to extract information on the brain dynamics. It mainly targets brain status and communication, thus providing potential to trace differences in the brain's activity under different anesthetics. In this article, two kinds of gamma-amino butyric acid (type A -GABAA) dependent anesthetic agents, propofol and desflurane (28 and 23 patients), were studied and compared with respect to EEG spectrogram dynamics. Hilbert-Huang Transform (HHT) was employed to compute the time varying spectrum for different anesthetic levels in comparison with Fourier based method. Results show that the HHT method generates consistent band power (slow and alpha) dominance pattern as Fourier method does, but exhibits higher concentrated power distribution within each frequency band than the Fourier method during both drugs induced unconsciousness. HHT also finds slow and theta bands peak frequency with better convergence by standard deviation (propofol-slow: 0.46 to 0.24; theta: 1.42 to 0.79; desflurane-slow: 0.30 to 0.25; theta: 1.42 to 0.98) and a shift to relatively lower values for alpha band (propofol: 9.94 Hz to 10.33 Hz, desflurane 8.44 Hz to 8.84 Hz) than Fourier one. For different stage comparisons, although HHT shows significant alpha power increases during unconsciousness stage as the Fourier did previously, it finds no significant high frequency (low gamma) band power difference in propofol whereas it does in desflurane. In addition, when comparing the HHT results within two groups during unconsciousness, high beta band power in propofol is significantly larger than that of desflurane while delta band power behaves oppositely. In conclusion, this study convincingly shows that EEG analyzed here considerably differs between the HHT and Fourier method.

Analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in functional endoscopic sinus surgery

Anesthesia technique may contribute to the improvement of operation room (OR) efficiency by reducing anesthesia-controlled time. We compared the difference between propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia (DES) for functional endoscopic sinus surgery (FESS) undergoing general anesthesiaWe performed a retrospective study using data collected in our hospital to compare the anesthesia-controlled time of FESS using either TIVA via target-controlled infusion with propofol/fentanyl or DES/fentanyl-based anesthesia between January 2010 and December 2011. The various time intervals (surgical time, anesthesia time, extubation time, total OR stay time, post anesthesia care unit [PACU] stay time) and the percentage of prolonged extubation were compared between the 2 anesthetic techniques.We included data from 717 patients, with 305 patients receiving TIVA and 412 patients receiving DES. An emergence time >15 minutes is defined as prolonged extubation. The extubation time was faster (8.8 [3.5] vs. 9.6 [4.0] minutes; P = .03), and the percentage of prolonged extubation was lower (7.5% vs. 13.6%, risk difference 6.1%, P < .001) in the TIVA group than in the DES group. However, there was no significant difference between ACT, total OR stay time, and PACU stay time.In our hospital, propofol-based TIVA by target-controlled infusion provide faster emergence and lower chance of prolonged extubation compared with DES anesthesia in FESS. However, the reduction in extubation time may not improve OR efficiency.

Efficacy of sevoflurane as an adjuvant to propofol-based total intravenous anesthesia for attenuating secretions in ocular surgery

BACKGROUND

The incidence of nasal secretions into the operative field is as high as 5% in ophthalmic surgery under general anesthesia. It may induce postoperative endophthalmitis. Secretions under propofol-based total intravanous anesthesia (TIVA) are greater than sevoflurane anesthesia during surgery. Postoperative nausea and vomiting (PONV) after inhalational anesthesia is higher than TIVA and may increase intraocluar pressure. We investigated the effect of sevoflurane combination with propofol-based TIVA on nasopharyngeal secretions and PONV in ocular surgery.

METHODS

Fifty patients undergoing ocular operations were randomly assigned for propofol-based TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 25), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane group (n = 25), 1% sevoflurane anesthesia was added.

RESULTS

Nasopharyngeal excretion volume was significantly higher in the propofol-based TIVA group than in the propofol/sevoflurane group (31.0 ± 18.1 vs 13.7 ± 12.6 ml; P < .001). No significant difference in extubation time was noted (propofol-based TIVA: 6.4 ± 3.6 vs propofol/sevoflurane: 7.4 ± 3.0 minutes; P = .34). No postoperative endophthalmitis or PONV in both groups was observed.

CONCLUSION

Sevoflurane attenuated secretions under propofol-based TIVA and did not increase the incidence of PONV or prolonged extubation in ocular surgery.

Relationship between anesthesia and postoperative endophthalmitis: A retrospective study

Previous study showed that patients under general anesthesia (GA) had nasopharyngeal secretions on the face at the end of ocular surgery, especially in propofol-based total intravenous anesthesia (TIVA), it might induce postoperative endophthalmitis. Therefore, we conducted a retrospective study to compare the incidence of endophthalmitis after ocular surgery under topical, inhalation anesthesia, and propofol-based TIVA in our medical center from 2011 to 2015.A total of 21,032 patients were included, and we evaluated epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of ocular surgery, method of antibiotic prophylaxis, vitreous culture, and vision outcome in these patients.Fifteen endophthalmitis cases among 21,032 operations reported, equaling an incidence of 0.071%. The incidence rates under topical, inhalation anesthesia, and propofol-based TIVA were 0.083%, 0.039%, and 0%, respectively (P = 0.39). Moreover, the risk of endophthalmitis under GA (0.024%) was significantly lower than topical anesthesia (0.083%) (P < 0.001). We also found that elder was the risk factor for endophthalmitis following ocular surgery.In conclusion, propofol-based TIVA or inhalation anesthesia did not increase the risk of endophthalmitis after ocular surgery. Thus, GA was not a risk factor for postoperative endophthalmitis. By contrast, elder was the risk factor for postoperative endophthalmitis.

Planning for operating room efficiency and faster anesthesia wake-up time in open major upper abdominal surgery

Reducing anesthesia-controlled time (ACT) may improve operation room (OR) efficiency result from different anesthetic techniques. However, the information about the difference in ACT between desflurane (DES) anesthesia and propofol-based total intravenous anesthesia (TIVA) techniques for open major upper abdominal surgery under general anesthesia (GA) is not available in the literature.This retrospective study uses our hospital database to analyze the ACT of open major upper abdominal surgery without liver resection after either desflurane/fentanyl-based anesthesia or TIVA via target-controlled infusion with fentanyl/propofol from January 2010 to December 2011. The various time intervals including waiting for anesthesia time, anesthesia time, surgical time, extubation time, exit from OR after extubation, total OR time, and postanesthetic care unit (PACU) stay time and percentage of prolonged extubation (≥15 minutes) were compared between these 2 anesthetic techniques.We included data from 343 patients, with 159 patients receiving TIVA and 184 patients receiving DES. The only significant difference is extubation time, TIVA was faster than the DES group (8.5 ± 3.8 vs 9.4 ± 3.7 minutes; P = 0.04). The factors contributed to prolonged extubation were age, gender, body mass index, DES anesthesia, and anesthesia time.In our hospital, propofol-based TIVA by target-controlled infusion provides faster emergence compared with DES anesthesia; however, it did not improve OR efficiency in open major abdominal surgery. Older, male gender, higher body mass index, DES anesthesia, and lengthy anesthesia time were factors that contribute to extubation time.